The First Five (Lessons in EMS)

This post was inspired by yet another person on The Twitter – @jessandra111! She’s a new paramedic graduate, heading to start her career in a big and busy city. She had asked the question of what lessons one who has been in the field might pass on to a new medic. While I don’t claim my experience to be definitive, these are some of the lessons about EMS that I have learned in my time. As I keep scribbling more notes to myself, I realize this instillation will be probably the first of four, broken into five thoughts at a time. There are so many lessons that I’ve thought of. Thank you, Jess, for carrying the torch into the next generation of pre-hospital excellence! Hopefully, I can act as the Sensei above, sharing my learned experiences and things that have brought me success and safety in my EMS practice.

1: Always prioritize your personal health.

The first and most important thing is personal health. This includes the physical, psychological, and spiritual/emotional facets of who we are as complete human beings. There are all sorts of ways to do this, and they’re all intertwined. Exercise and physical strength benefits you both in your capability to do the job (lifting, driving, carrying bags, etc.), but also allows you to burn through the catecholamines that build up over the course of the shift. We have to remember that all of those neurotransmitters and sympathetic hormones affect not only our physical health, but our psychological health as well. This includes better sleep cycles, more stable interpersonal relationships, and helps keep us from compassion fatigue.

This all ties into how we treat ourselves as spiritual or emotional beings. The concept of the “beauty to death ratio” is a great way to look at this. We need to make sure that we build beauty into our lives, so that we don’t become blinded to the fact that our reality isn’t actually real life for most people. Real life, apart from EMS, is full of beauty, happiness, love, and good people. Addressing these three aspects of ourselves will help keep you from becoming jaded or burnt out.

2: Look out for your partner.

As much as our society tries to tell us that we’re not our brothers’ or sisters’ keepers, in this job, I think we have to be. This doesn’t mean imposing our worldviews or moral values on people, but it does mean looking out for people. It means saying, “You’re important, your life matters, and therefore your safety and health matter to me.” I’ve been in the situation two or three times where I’ve had to put a unit out of service, or call a supervisor even when I’m off duty, if I hear about a friend or partner who is potentially depressed or suicidal. While those have made for some very difficult short-term relationships, the long-term benefits of gratitude that have been expressed when someone knows that they are cared about unconditionally is absolutely worth the uncomfortable moment. When you spend as much time as we do with our partners, we can learn a lot about them. Keep an eye on them after a potentially hard call. See if their mood is changing, or if they are more easily irritable. Don’t be afraid to ask them point blank, “Hey… are you doing alright? I’m worried.”

3: Reputation is earned every day.

It’s amazing how subtle and profound this one can be. Reputation is formed from the moment you show up to your very first shift as a student. It means being on time, ready to work, with a good attitude. It means not dodging the annoying work around the station, but being a team player. It means addressing superiors by their rank or title. It means addressing patients by proper names or “Sir/Ma’am”, until given permission to do otherwise, regardless of who the patient is. It means checking your equipment every day, showing up in a clean uniform, tucking your shirt in and having clean shoes. It includes taking pride in your appearance, and the appearance of your truck (if its dirty, wash it, its not that hard!). It means not complaining, not getting angry, or at least knowing when to have those moments. And it certainly revolves around your clinical care.

The most important thing to remember about reputation is that the community that we work in is small. Your reputation follows you wherever you go. Reputation has to be earned, just like respect. In the public safety community, your reputation does not start 100/100, and then work your way down. People look at you skeptically until you prove yourself, so be willing to put out the best effort possible in every situation. And, in the blink of an eye, reputation can be lost. Everybody is watching, making judgements, and filing away how you handle yourself, practice your medicine, and how you treat people. Be willing to work hard and fight passionately to maintain yours!

4: Slow is steady, steady is smooth, and smooth is fast.

Public safety, like the military, is built on lessons learned, and those lessons are usually learned how from failure and not successes. I’m fond of studying military and medical axioms, because in a profession with a strong oral tradition, we can learn much from witty little sayings our seniors dole out like candy that actually hold decades or centuries of experience. One of my favorite is in regards to clinical care. I first heard this years ago well reading about the United States Navy SEALs. The idea is this: slow is steady, steady is smooth, and smooth is fast.

Breaking it down, “slow is steady” means to consciously slow your breathing, slow your speech, and be decisive about your actions. I usually start this on the way to a call if I know that there is going to be the potential of a lot of stress. I’ll give an example: I responded to a call of a two year old who drowned in a toilet. We had updates enroute from dispatch, and then police on scene, stating that they were starting CPR, and that the airway was compromised. I remember sitting in my seat, slowing my breathing, and telling myself, “I am cold. I am steady. I am not going to panic. I am in control, and I will feel nothing.” I said this to myself over and over, until I physically started to feel colder. That was the clinically best run pediatric call I’ve ever had. I never raised my voice, never got out of control, and brought a sense of calm to the scene that my new parter and new firefighter stated later that they fed off of. It’s a cheesy thing to do, but that kind of zen state enroute to a call is something I’ve always done, and works for me. “Steady is smooth” means that as you slow down what you can control such as breathing or your mental space, your physical actions become easier to control. There’s excellent evidence that once one’s heart rate increases past 120 beats per minute, it becomes more difficult to have situational awareness and fine motor control. This is incredibly important in a job with as much cognitive strain and absolute need for fine motor control as we do as advanced prehospital providers. Whether it’s intubating someone, working out drug dosages, starting IVs on your patient… All these will benefit from a smooth approach, not stabbing someone blindly with a needle or bullying a tube into a hole that you’re not sure is their trachea.

By being slow and steady, you actually do things much more quickly and efficiently than if you rushed through the process. Not only will you be more accurate and successful in your first attempt at a procedure, recalling a protocol, or communicating on the radio, but with that effectiveness, you won’t have to repeat anything. Your scene times will be faster, and you’ll be able to accomplish more in the back of the ambulance. People always thought it was crazy that in a 6 block transport with a major trauma patient, I could still have oxygen, monitor, oxygen saturation, capnography, blood glucose, two large bore IV’s (barely running, but able to be used at the trauma center – permissive hypotension people!), a complete physical exam, and two sets of vitals done.

It may seem like a cheese-ball of a saying, but it has been tested in the harshest of environments and stood the test of time, and is worth ingraining into your soul.

5: Everyone can hurt you, but its not about “us vs. them”

One of the first things that I was taught – maybe the very first conversation I had with my preceptors on day one of my field internship – was them telling me to always remember that everyone can hurt you. This Sobering message that actually kept me from significant physical harm or even kept me alive in some very sticky situations.

It is true though, that everyone has the potential to hurt you. The first time as a paramedic on my own but I don’t with a firearm on scene, it was an elderly patient in her early 90s who was altered and septic, and kept reaching for something over her head. I assumed that she was about to start seizing her that this was some kind of repetitive motion due to her altered mental status. My partner, who is much more seasoned and situationally aware, looks to see where her hands kept going, and found a small 25 caliber handgun, with four rounds in the magazine and one in the chamber. I will never forget Andrew pulling the magazine out and pulling the slide back on the weapon, and watching that round of ammunition fly into the air. My heart stopped. it never occurred to me that an altered elderly patient might actually be trying to defend yourself from people she had no concept of, and had she found her firearm, it wouldn’t have mattered the reason why she pulled the trigger. One of us would’ve been just as hurt or dead.

This experience stuck with me. I learned to wake up the apparently drunk patient after patting them down gently to check for obvious weapons, and then putting their hand and a wrist lock so that I could control them should they become violent. One night in about two in the morning, this kept me from getting stabbed with the switchblade. I could share more experiences, but I think this demonstrates my point.

Working in an urban environment where there was a lot of gang violence, I was always checking people for weapons. Many times people were under the influence of alcohol or chemicals. The repeated exposure to this kind of violence, both directed at other people and directed at myself, definitely hardened my interior. I came to a dangerous place where I realized I had a very much “us against them “mentality. and I actually do think that, to a degree, there is an us/them component to the world. No one understands what we do, and no one looks out for us like our brothers and sisters on the ambulance, our firefighters , or police officers. we always try and watch each other’s backs.

The danger those assuming that everyone is out to hurt you. The perspective I gained with some wisdom, demonstrated to me that I had been completely wrong. Most people, regardless of socioeconomic standing, just wanted to live and work in love and raise families in peace. A small percentage of the population created the rest of the problems. I think we all know the districts in our area of operations that most of the violence and chemically altered patients come from. It becomes easy to stereotype and generalize anyone from that area as being a troublemaker. But they aren’t, not the least.

So well it’s easy to feel like it is us against them, remember that everyone deserves to be treated with respect. You can defuse most of the fights by treating people well. You can still look after your coworkers without falling victim to the cognitive biases that accumulate over time if you’re willing to recognize the fact that they exist.

But never forget: it is an incredibly dangerous job. And yes, some people will want to hurt you. Talk to your police officers in your area. Learn how to search people well. Learn how to look at people’s hands and eyes and body language. Do right along’s with local lawn force meant and have them teach you. That kind of knowledge can literally save your life.

So that’s the first installment. I think I’ll be posting these in five point posts, and mix those up with some stories from my career. I hope this helps my friends at any point in their career! Thanks again to Jess for the inspiration to write this post, for my other friend Jess (@jkwillettmd) for convincing me to start this blog, and my friend Ginger for proofreading. Life is a team sport! Be safe out there, my people!